- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.59 / $255.59 / $257.01
| Professional | | $255.59 | $255.59 | $257.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.75 / $1,363.75 / $1,363.75
| Professional | | $1,363.75 | $1,363.75 | $1,363.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.53 / $431.98 / $1,363.75
| Professional | | $339.53 | $431.98 | $1,363.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.53 / $431.98 / $1,363.75
| Professional | | $339.53 | $431.98 | $1,363.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.77 / $375.48 / $1,450.67
| Professional | | $245.77 | $375.48 | $1,450.67 |